Investigation Report
Equinor – Mongstad – investigation of personal injury and steam escape
Equinor – Mongstad – investigation of personal injury and steam escape
- Havtil
- Investigation Report
- Unknown
- Falls from heightIncident investigationLoss of containmentPressure systemsRisk management
- Inspection and maintenanceWorking at height
- HoseProcess pipework and pipelinesScaffoldValve
- Operating and work proceduresPositive retention and reliable securingRisk assessmentSafety communication
- Downstream and process industries
- Onshore facility
Summary
Investigates a steam release during drainage of boiler low points at Mongstad. An operator escaping the steam fell or slid about four–five metres, sustaining minor torso injuries and a sprained ankle. HTO and Five Whys analysis identified shortcomings in risk assessment, hose securing, work planning and information transfer following a personnel change.
Classifications: Falls from height; fall from height.
Classifications: Incident investigation; accident investigation.
Classifications: Loss of containment; containment loss.
Classifications: Pressure systems; stored pressure; pressurised systems; pressurized systems.
Classifications: Risk management; risk evaluation.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Working at height; work at height.
Classifications: Hose; flexible hose.
Classifications: Process pipework and pipelines; process piping.
Classifications: Scaffold; scaffolding.
Classifications: Valve; valves.
Classifications: Operating and work procedures.
Classifications: Positive retention and reliable securing.
Classifications: Risk assessment; hazard assessment.
Classifications: Safety communication; toolbox talk; toolbox talks.
Classifications: Downstream and process industries; refining; petrochemicals.
Classifications: Onshore facility; onshore plant.